As 2019 comes to a close, it is interesting to reflect on where we stand with glaucoma management today. Interestingly, based on data from the Ocular Hypertension Treatment Study¹ and other assessments of the glaucoma market today, it is believed that up to half of treated glaucoma patients are receiving 2 topical glaucoma medications. On the one hand, I can see some good in this statistic. Treating patients with more than 1 medication gives me hope that we recognize glaucoma as a serious and irreversible disease that should be treated early, often, and aggressively. I am hopeful that we are targeting low pressures and using several therapies if necessary to get the job done.

On the other hand, using more than 1 eye drop in half of our patients raises some concerns. Very few patients are receiving laser trabeculoplasty as primary therapy, and if this were the case, we would not need to use so many medications. Generic latanoprost is popular today, but I will always wonder if we could avoid a second bottle if we used more potent prostaglandin analogues. One possible reason that we use so many medications is that we may not always remember to de-escalate therapy after we have performed cataract surgery, MIGS, or laser. Consider that in the COMPASS trial, when the terminal washout was performed and Cypass (Alcon) patients were taken off their medications, their pressure did not rise very much, on average.² We are probably better at starting drops than we are at stopping them.

Has MIGS cut into the need for multiple glaucoma medications? I don’t have an answer to that, but it is important to note that we cannot get reimbursement for standalone trabecular bypass stents. Currently, only goniotomy, cyclophotocoagulation, and canaloplasty are covered by insurance payers without cataract extraction.

Finally, we await the arrival of sustained drug delivery. Based on data released by Allergan for its sustained-release program, a large percentage of patients may be controlled without topical agents even 1 year after the last intracameral drug implant is delivered.

Thinking back to half of the glaucoma patients requiring 2 medications, we can look to this issue of Glaucoma Physician for some enlightenment. It is good that we are being aggressive, but we should be creative in terms of diagnostics and IOP-lowering therapies, and we should take advantage of all the tools at our disposal. In this issue, we discuss combined MIGS, micropulse laser, corneal hysteresis, and a variety of other IOP-lowering procedures. GP

References

1. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):701-13; discussion 829-30.
2. Vold S, Ahmed II, Craven ER, et al; CyPass Study Group. Two-year COMPASS trial results: supraciliary microstenting with phacoemulsification in patients with open-angle glaucoma and cataracts. Ophthalmology. 2016;123(10):2103-2112.

Dr. Radcliffe is a clinical assistant professor in the department of ophthalmology at the NYU Langone Medical Center and a surgeon at the New York Eye Surgery Center.